Introducing a novel respiratory function monitor for neonatal resuscitation training.

Background: A respiratory function monitor (RFM) gives immediate feedback, allowing clinicians to adjust face mask ventilation to correct leak or inappropriate tidal volumes. We audited the satisfaction of clinicians with a neonatal resuscitation training package, incorporating a novel RFM. Methods: This was a mixed-methods study conducted at The Royal Women's Hospital, Melbourne, Australia. Clinicians were approached to complete a neonatal resuscitation training session. Participants watched a training video, then provided ventilation to term and preterm manikins first without, and then with, the RFM. Clinicians completed a survey after the session and undertook a follow-up session three months later. The primary outcome was participant satisfaction with the RFM. Secondary outcomes included participants' self-assessment of face mask leak and tidal volumes when using the RFM. Results: Fifty clinicians completed both the initial and follow-up session. Participants reported high levels of satisfaction with the RFM for both term and preterm manikins: on a scale from 0, meaning "not at all", and 100, meaning "yes, for all resuscitations", the median response (interquartile range, IQR) was 82 (74-94) vs 81.5 (69-94.5). Levels of satisfaction were similar for less experienced and more experienced clinicians: median (IQR) 83 (77-93) vs 81 (71.5-95) respectively. When using the monitor, clinicians accurately self-assessed that they achieved leak below 30% and tidal volumes within the target range at least 80% of the time. Conclusion: Clinicians of all experience levels had a high level of satisfaction with a training package including a novel RFM.

A touch of hierarchy: population receptive fields reveal fingertip integration in Brodmann areas in human primary somatosensory cortex.

Several neuroimaging studies have shown the somatotopy of body part representations in primary somatosensory cortex (S1), but the functional hierarchy of distinct subregions in human S1 has not been adequately addressed. The current study investigates the functional hierarchy of cyto-architectonically distinct regions, Brodmann areas BA3, BA1, and BA2, in human S1. During functional MRI experiments, we presented participants with vibrotactile stimulation of the fingertips at three different vibration frequencies. Using population Receptive Field (pRF) modeling of the fMRI BOLD activity, we identified the hand region in S1 and the somatotopy of the fingertips. For each voxel, the pRF center indicates the finger that most effectively drives the BOLD signal, and the pRF size measures the spatial somatic pooling of fingertips. We find a systematic relationship of pRF sizes from lower-order areas to higher-order areas. Specifically, we found that pRF sizes are smallest in BA3, increase slightly towards BA1, and are largest in BA2, paralleling the increase in visual receptive field size as one ascends the visual hierarchy. Additionally, we find that the time-to-peak of the hemodynamic response in BA3 is roughly 0.5 s earlier compared to BA1 and BA2, further supporting the notion of a functional hierarchy of subregions in S1. These results were obtained during stimulation of different mechanoreceptors, suggesting that different afferent fibers leading up to S1 feed into the same cortical hierarchy.

Antenatal sildenafil treatment improves neonatal pulmonary hemodynamics and gas exchange in lambs with diaphragmatic hernia.

OBJECTIVES: Infants with congenital diaphragmatic hernia (CDH) are predisposed to pulmonary hypertension after birth, owing to lung hypoplasia that impairs fetal pulmonary vascular development. Antenatal sildenafil treatment attenuates abnormal pulmonary vascular and alveolar development in rabbit and rodent CDH models, but whether this translates to functional improvements after birth remains unknown. We aimed to evaluate the effect of antenatal sildenafil on neonatal pulmonary hemodynamics and lung function in lambs with diaphragmatic hernia (DH). METHODS: DH was surgically induced at approximately 80 days' gestation in 16 lamb fetuses (term in lambs is approximately 147 days). From 105 days' gestation, ewes received either sildenafil (0.21 mg/kg/h intravenously) or saline infusion until delivery (n = 8 fetuses in each group). At approximately 138 days' gestation, all lambs were instrumented and then delivered via Cesarean section. The lambs were ventilated for 120 min with continuous recording of physiological (pulmonary and carotid artery blood flow and pressure; cerebral oxygenation) and ventilatory parameters, and regular assessment of arterial blood gas tensions. Only lambs that survived until delivery and with a confirmed diaphragmatic defect at postmortem examination were included in the analysis; these comprised six DH-sildenafil lambs and six DH-saline control lambs. RESULTS: Lung-to-body-weight ratio (0.016 ± 0.001 vs 0.013 ± 0.001; P = 0.06) and dynamic lung compliance (0.8 ± 0.2 vs 0.7 ± 0.2 mL/cmH2 O; P = 0.72) were similar in DH-sildenafil lambs and controls. Pulmonary vascular resistance decreased following lung aeration to a greater degree in DH-sildenafil lambs, and was 4-fold lower by 120 min after cord clamping than in controls (0.6 ± 0.1 vs 2.2 ± 0.6 mmHg/(mL/min); P = 0.002). Pulmonary arterial pressure was also lower (46 ± 2 vs 59 ± 2 mmHg; P = 0.048) and pulmonary blood flow higher (25 ± 3 vs 8 ± 2 mL/min/kg; P = 0.02) in DH-sildenafil than in DH-saline lambs at 120 min. Throughout the 120-min ventilation period, the partial pressure of arterial carbon dioxide tended to be lower in DH-sildenafil lambs than in controls (63 ± 8 vs 87 ± 8 mmHg; P = 0.057), and there was no significant difference in partial pressure of arterial oxygen between the two groups. CONCLUSIONS: Sustained maternal antenatal sildenafil infusion reduced pulmonary arterial pressure and increased pulmonary blood flow in DH lambs for the first 120 min after birth. These findings of improved pulmonary vascular function are consistent with improved pulmonary vascular structure seen in two previous animal models. The data support the rationale for a clinical trial investigating the effect of antenatal sildenafil in reducing the risk of neonatal pulmonary hypertension in infants with CDH. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Encuesta española de reanimación neonatal 5 años después. ¿Vamos mejorando? / Five years after the Spanish neonatal resuscitation survey. Are we improving?

INTRODUCCIÓN: Se analizan prácticas de reanimación neonatal en salas de partos (SP) de centros hospitalarios españoles. MÉTODOS: Se envió un cuestionario por centro a neonatólogos responsables de la atención del RN en SP de hospitales españoles. RESULTADOS: De 180 cuestionarios enviados, se cumplimentaron 155 (86%); 71 centros fueron de nivel I-II(46%) y 84 de nivel III (54%). La familia y el equipo médico participaron en decisiones de no reanimar o interrumpir la reanimación en el 74,2% de los centros. La disponibilidad de 2 o más reanimadores fue del 80% (94,0% en nivel II I y 63,9% en nivel I-II, p < 0,001). En un 90,3% de centros se realizan cursos de Reanimación. En centros de nivel III fueron más frecuentes los mezcladores de gases, pulsioxímetros, ventiladores manuales y envoltorios de plástico. El uso de envoltorios de polietileno fue del 63,9%. En RN a término se inició la reanimación con aire en el 89,7% de los centros. El dispositivo más usado para aplicar VPP fue el «ventilador manual» (78,6% en nivel III y 42,3% en nivel I-II, p < 0,001). En el 91,7% de los centros de nivel III se utilizó CPAP precoz en prematuros. En los últimos 5 años han mejorado prácticas como son la formación de profesionales, el uso de pulsioxímetros y de CPAP precoz. CONCLUSIONES: Existe una mejora progresiva en algunas prácticas de reanimación neonatal. Se encuentran diferencias en aspectos generales, equipamientos y protocolos de actuación durante la reanimación y transporte entre unidades de diferentes niveles

INTRODUCTION: An analysis is presented of delivery room (DR) neonatal resuscitation practices in Spanish hospitals. METHODS: A questionnaire was sent by e-mail to all hospitals attending deliveries in Spain. RESULTS: A total of 180 questionnaires were sent, of which 155 were fully completed (86%). Less than half (71, 46%) were level I or II hospitals, while 84 were level III hospital (54%). In almost three-quarters (74.2%) of the centres, parents and medical staff were involved in the decision on whether to start resuscitation or withdraw it. A qualified resuscitation team (at least two members) was available in 80% of the participant centres (63.9% level I-II, and 94.0% level III,P<.001). Neonatal resuscitation courses were held in 90.3% of the centres. The availability of gas blenders, pulse oximeters, manual ventilators, and plastic wraps was higher in level IIIhospitals. Plastic wraps for pre-term hypothermia prevention were used in 63.9% of the centres (40.8% level I-IIand 83.3% level III, P<.001). Term newborn resuscitation was started on room air in 89.7% of the centres. A manual ventilator (T-piece) was the device used in most cases when ventilation was required (42.3% level I-IIand 78.6% level III, P<.001). Early CPAP in preterm infants was applied in 91.7% of the tertiary hospitals. In last 5 years some practices have improved, such neonatal resuscitation training, pulse oximeter use, or early CPAP support. CONCLUSIONS: There is an improvement in some practices of neonatal resuscitation. Significant differences have been found as regards the equipment or practices in the DR, when comparing hospitals of different levels of care

[Five years after the Spanish neonatal resuscitation survey. Are we improving?]. / Encuesta española de reanimación neonatal 5 años después. ¿Vamos mejorando?

INTRODUCTION: An analysis is presented of delivery room (DR) neonatal resuscitation practices in Spanish hospitals. METHODS: A questionnaire was sent by e-mail to all hospitals attending deliveries in Spain. RESULTS: A total of 180 questionnaires were sent, of which 155 were fully completed (86%). Less than half (71, 46%) were level i or ii hospitals, while 84 were level iii hospital (54%). In almost three-quarters (74.2%) of the centres, parents and medical staff were involved in the decision on whether to start resuscitation or withdraw it. A qualified resuscitation team (at least two members) was available in 80% of the participant centres (63.9% level i-ii, and 94.0% level iii, P<.001). Neonatal resuscitation courses were held in 90.3% of the centres. The availability of gas blenders, pulse oximeters, manual ventilators, and plastic wraps was higher in level iii hospitals. Plastic wraps for pre-term hypothermia prevention were used in 63.9% of the centres (40.8% level i-iiand 83.3% level iii, P<.001). Term newborn resuscitation was started on room air in 89.7% of the centres. A manual ventilator (T-piece) was the device used in most cases when ventilation was required (42.3% level i-iiand 78.6% level iii, P<.001). Early CPAP in preterm infants was applied in 91.7% of the tertiary hospitals. In last 5 years some practices have improved, such neonatal resuscitation training, pulse oximeter use, or early CPAP support. CONCLUSIONS: There is an improvement in some practices of neonatal resuscitation. Significant differences have been found as regards the equipment or practices in the DR, when comparing hospitals of different levels of care.

Assessing the tongue colour of newly born infants may help to predict the need for supplemental oxygen in the delivery room.

AIM: It takes several minutes for infants to become pink after birth. Preductal oxygen saturation (SpO2) measurements are used to guide the delivery of supplemental oxygen to newly born infants, but pulse oximetry is not available in many parts of the world. We explored whether the pinkness of an infant's tongue provided a useful indication that supplemental oxygen was required. METHODS: This was a prospective observational study of infants delivered by Caesarean section. Simultaneous recording of SpO2 and visual assessment of whether the tongue was pink or not was made at 1-7 and 10 min after birth. RESULTS: The 38 midwives and seven paediatric trainees carried out 271 paired assessments on 68 infants with a mean (SD) birthweight of 3214 (545) grams and gestational age of 38 (2) weeks. When the infant did not have a pink tongue, this predicted SpO2 of <70% with a sensitivity of 26% and a specificity of 96%. CONCLUSION: Tongue colour was a specific but insensitive sign that indicated when SpO2 was <70%. When the tongue is pink, it is likely that an infant has an SpO2 of more than 70% and does not require supplemental oxygen.

The precision and accuracy of Nellcor and Masimo oximeters at low oxygen saturations (70%) in newborn lambs.

BACKGROUND: Administration of oxygen in the delivery room is informed by oxygen saturation (SpO2). An oxygen saturation range of 60%-70% is the threshold for administering oxygen in the first minutes after birth. The accuracy of newer generation oximeters to measure SpO2 has not been compared against the 'gold standard', direct arterial blood oxygen saturation (SaO2) when SaO2 is low. The aim of this study was to determine the accuracy and precision of Nellcor and Masimo oximeters to measure SpO2 when SaO2 <70%. METHOD: Prospective observational study in ventilated anaesthetised newborn lambs with an indwelling carotid artery catheter. Ventilation was adjusted to achieve hypoxaemia. Nellcor (Oxi-Max 600 with Max-N sensor) and Masimo (Rad 4 with low noise optical probe (LNOP) sensor) sensors were applied to the right forelimb (preductal). An arterial blood sample was collected at 1-5 min intervals when the animal was hypoxic. The displayed SpO2 was recorded. We used Bland-Altman analysis to determine precision and accuracy of each oximeter when SaO2 <70%. RESULTS: 17 lambs were studied, 165 measurements were obtained, 123 were SaO2 <70%. The mean difference (±1.96 SD) Nellcor SpO2-SaO2 when SaO2 <70% was 17% (-12% to 46%). The mean difference (±1.96 SD) Masimo SpO2-SaO2 when SaO2 <70% was 13% (-19% to 45%). CONCLUSIONS: At SaO2<70%, both monitors overestimated oxygen saturation (SpO2) compared with the gold standard. Both oximeters were equally inaccurate when SaO2 was low.

Self-inflating bags versus T-piece resuscitator to deliver sustained inflations in a preterm lamb model.

OBJECTIVE: In neonatal resuscitation, the use of a sustained inflation (SI) may facilitate lung aeration. Previous studies comparing different resuscitation devices have shown that one model of self-inflating bag (SIB) could not deliver an SI. We aimed to compare the delivery of an SI using four SIBs with that of a T-piece. STUDY DESIGN: In intubated preterm lambs, we compared four models of SIB fitted with a positive end expiratory pressure (PEEP) valve to a T-piece using a gas flow of 8 L/min. Four operators aimed to deliver three SIs of 20 cm H2O for 30 s. The study was repeated with the PEEP valve removed and again with no flow. We measured duration of SI, average inflation pressure (IP) and analysed the shape of the pressure curves. RESULTS: 204 combinations were analysed. Mean (SD) duration of SI was Ambu 6(2)s, Laerdal 14(8)s, Parker Healthcare 5(1)s, Mayo Healthcare 33(2)s and T-piece 33(1)s. Mean (SD) average IP was Ambu 17(3)cm H2O, Laerdal 17(3)cm H2O, Parker Healthcare 12(5)cm H2O, Mayo Healthcare 21(2)cm H2O and T-piece 20(0)cm H2O. Duration of SI and average IP was significantly different between SIBs (all p<0.001). The findings were substantially unchanged when PEEP valve and flow were removed (all p>0.05). Only the Mayo system delivered SIs with duration and average IP not significantly different from the T-piece (p>0.05). CONCLUSIONS: The performance of the four SIBs tested varied considerably. Some are able to deliver an SI even in the absence of gas flow. This may be useful in a resource-limited setting with no gas supply.

The risk for hyperoxaemia after apnoea, bradycardia and hypoxaemia in preterm infants.

OBJECTIVE: To investigate the occurrence and duration of oxygen saturation (SpO2) ≥95%, after extra oxygen for apnoea, bradycardia, cyanosis (ABC), and the relation with the duration of bradycardia and/or SpO2 ≤80%. METHODS: All preterm infants <32 weeks' gestation supported with nasal continuous positive airway pressure (nCPAP) admitted to our centre were eligible for the study. We retrospectively identified all episodes of ABCs. In ABCs where oxygen supply was increased, duration and severity of bradycardia (<80 bpm), SpO2 ≤80%, SpO2 ≥95% and their correlation were investigated. RESULTS: In 56 infants, 257 ABCs occurred where oxygen supply was increased. SpO2 ≥95% occurred after 79% (202/257) of the ABCs, duration of extra oxygen supply was longer in ABCs with SpO2 ≥95% than without SpO2 ≥95% (median (IQR) 20 (8-80) vs 2 (2-3) min; p<0.001)). The duration of SpO2 ≥95% was longer than bradycardia and SpO2 ≤80% (median (IQR) 13 (4-30) vs 1 (1-1) vs 2 (1-2) min; p<0.001). SpO2 ≥95% lasted longer when infants were in ambient air than when oxygen was given before the ABC occurred (median (IQR)15 (5-38) min vs 6 (3-24) min; p<0.01). CONCLUSIONS: In preterm infants supported with nCPAP in the neonatal intensive care unit (NICU), SpO2 ≥95% frequently occurred when oxygen was increased for ABCs and lasted longer than the bradycardia and SpO2 ≤80%.

Comparison of heart rate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants.

AIM: To compare heart rate (HR) measurements from Masimo and Nellcor pulse oximeters (POs) against HR measured via a three lead electrocardiograph (ECG) (HRECG ). We also compared peripheral oxygen saturation (SpO2 ) measurements between Nellcor and Masimo oximeters. METHOD: Term infants born via elective caesarean section were studied. ECG leads were placed on the infant's chest and abdomen. Masimo and Nellcor PO sensors were randomly allocated to either foot. The monitors were placed on a trolley, and data from each monitor screen captured by a video camera. HR, SpO2 measurements and signal quality were extracted. Bland-Altman analysis was used to determine agreement between HR from the ECG and each oximeter, and between SpO2 from the oximeters. RESULTS: We studied 44 infants of whom 4 were resuscitated. More than 8000 pairs of observations were used for each comparison of HR and SpO2. The mean difference (±2SD) between HRECG and HRN ellcor was -0.8 (±11) beats per minute (bpm); between HRECG and HRM asimo was 0.2 (±9) bpm. The mean (±2SD) difference between SpO2Masimo and SpO2Nellcor was -3 (±15)%. The Nellcor PO measured 20% higher than the Masimo PO at SpO2 <70%. CONCLUSION: Both oximeters accurately measure HR. There was good agreement between SpO2 measurements when SpO2 ≥70%. At lower SpO2 , agreement was poorer.

Validation of the continuous glucose monitoring sensor in preterm infants.

OBJECTIVE: Recent studies have highlighted the need for improved methods of monitoring glucose control in intensive care to reduce hyperglycaemia, without increasing the risk of hypoglycaemia. Continuous glucose monitoring is increasingly used in children with diabetes, but there are little data regarding its use in the preterm infant, particularly at extremes of glucose levels and over prolonged periods. This study aimed to assess the accuracy of the continuous glucose monitoring sensor (CGMS) across the glucose profile, and to determine whether there was any deterioration over a 7 day period. DESIGN: Prospectively collected CGMS data from the NIRTURE Trial was compared with the data obtained simultaneously using point of care glucose monitors. SETTING: An international multicentre randomised controlled trial. PATIENTS: One hundred and eighty-eight very low birth weight control infants. OUTCOME MEASURES: Optimal accuracy, performance goals (American Diabetes Association consensus), Bland Altman, Error Grid analyses and accuracy. RESULTS: The mean (SD) duration of CGMS recordings was 156.18 (29) h (6.5 days), with a total of 5207 paired glucose levels. CGMS data correlated well with point of care devices (r=0.94), with minimal bias. It met the Clarke Error Grid and Consensus Grid criteria for clinical significance. Accuracy of single readings to detect set thresholds of hypoglycaemia, or hyperglycaemia was poor. There was no deterioration over time from insertion. CONCLUSIONS: CGMS can provide information on trends in glucose control, and guidance on the need for blood glucose assessment. This highlights the potential use of CGMS in optimising glucose control in preterm infants.

Determining the best method of Nellcor pulse oximeter sensor application in neonates.

AIM: To identify the optimal sensor application method that gave the quickest display of accurate heart rate (HR) data using the Nellcor OxiMax N-600x pulse oximeter (PO). METHODS: Stable infants who were monitored with an electrocardiograph were included. Three sensor application techniques were studied: (i) sensor connected to cable, then applied to infant; (ii) sensor connected to cable, applied to investigator's finger, and then to infant; (iii) sensor applied to infant, then connected to cable. The order of techniques tested was randomized for each infant. Time taken to apply the PO sensor, to display data and to display accurate data (HR(PO) = HR(ECG) ± 3 bpm) were recorded using a stopwatch. RESULTS: Forty infants were studied [mean (SD) birthweight, 1455 (872) g; gestational age, 31 (4) weeks; post-menstrual age, 34 (4) weeks]. Method 3 acquired any data significantly faster than methods 1 (p = 0.013; CI, -9.6 to -3.0 sec) and 2 (p = 0.004; CI, -5.9 to -1.2 sec). Method 3 acquired accurate data significantly faster than method 1 (p = 0.016; CI, -9.4 to -1.0 sec), but not method 2 (p = 0.28). CONCLUSION: Applying the sensor to the infant before connecting it to the cable yields the fastest acquisition of accurate HR data from the Nellcor PO.

Adaptación de las recomendaciones internacionales sobre reanimación neonatal 2010: comentarios / Changes in the international recommendations on neonatal resuscitation, 2010: comments

Desde la publicación de las últimas recomendaciones ILCOR del 2005, los cambios más significativos que se han implementado en las del 2010 son los siguientes: valoración del recién nacido mediante 2 características vitales (frecuencia cardiaca y respiración) para decidir inicialmente el siguiente paso en la reanimación; evaluación de la oxigenación mediante monitorización por pulsioximetría (el color no es fiable); inicio de la reanimación con aire en el recién nacido a término en lugar de oxígeno al 100%; uso de mezcladores de oxígeno y aire para administrar oxígeno suplementario en caso de necesidad; controversia en la aspiración endotraqueal en recién nacidos deprimidos con aguas meconiales; la proporción de ventilación compresión sigue siendo de 3/1, excepto en la parada cardiorrespiratoria de origen cardiaco, en que se debería considerar una proporción más alta; indicación de hipotermia terapéutica en recién nacidos a término o casi término diagnosticados de encefalopatía hipóxico-isquémica moderada o grave con protocolos y seguimiento coordinados por el sistema regional perinatal (cuidados posreanimación); retraso de al menos 1 min en la ligadura del cordón umbilical de recién nacidos que no requieren reanimación (no existe suficiente evidencia para recomendar un tiempo de ligadura de cordón en aquellos que requieren reanimación), y si no se detecta latido cardiaco después de 10 min de una correcta reanimación, se acepta desde un punto de vista ético, la posibilidad de interrumpir la reanimación, aunque muchos factores contribuyen a la decisión de seguir más allá de 10 min. En determinadas situaciones, no iniciar la reanimación se puede plantear teniendo en cuenta las recomendaciones generales, los resultados propios y la opinión de los padres (AU)

Since previous publication in 2005, the most significant changes that have been addressed in the 2010 International Liaison Committee on Resuscitation (ILCOR) recommendations are as follows: (I) use of 2 vital characteristics (heart rate and breathing) to initially evaluate progression to the following step in resuscitation; (II) oximetry monitoring for the evaluation of oxygenation (assessment of color is unreliable); (III) for babies born at term it is better to start resuscitation with air rather than 100% oxygen; (IV) administration of supplementary oxygen should be regulated by blending oxygen and air; (V) controversy about endotraqueal suctioning of depressed infants born through meconium-stained amniotic fluid; (VI) chest compression-ventilation ratio should remain at 3/1 for neonates unless the arrest is known to be of cardiac etiology, in which case a higher ratio should be considered; (VII)use of therapeutic hypothermia for infants born at term or near term evolving to moderate or severe hypoxic-ischemic encephalopathy, with protocol and follow-up coordinated through a regional perinatal system (post-resuscitation management); (VIII) cord clamping delay for at least 1 minute in babies who do not require resuscitation (there is insufficient evidence to recommend a time for clamping in those who require resuscitation) and, (IX) it is appropriate to consider discontinuing resuscitation if there has been no detectable heart rate for 10 minutes, although many factors contribute to the decision to continue beyond 10 minutes. Under certain circumstances, non-initiation of resuscitation could be proposed taking into consideration general recommendations, own results and parents’ opinion (AU)

[Changes in the international recommendations on neonatal resuscitation, 2010: comments]. / Adaptación de las recomendaciones internacionales sobre reanimación neonatal 2010: comentarios.

Since previous publication in 2005, the most significant changes that have been addressed in the 2010 International Liaison Committee on Resuscitation (ILCOR) recommendations are as follows: (i) use of 2 vital characteristics (heart rate and breathing) to initially evaluate progression to the following step in resuscitation; (ii) oximetry monitoring for the evaluation of oxygenation (assessment of color is unreliable); (iii) for babies born at term it is better to start resuscitation with air rather than 100% oxygen; (iv) administration of supplementary oxygen should be regulated by blending oxygen and air; (v) controversy about endotraqueal suctioning of depressed infants born through meconium-stained amniotic fluid; (vi) chest compression-ventilation ratio should remain at 3/1 for neonates unless the arrest is known to be of cardiac etiology, in which case a higher ratio should be considered; (vii) use of therapeutic hypothermia for infants born at term or near term evolving to moderate or severe hypoxic-ischemic encephalopathy, with protocol and follow-up coordinated through a regional perinatal system (post-resuscitation management); (viii) cord clamping delay for at least 1 minute in babies who do not require resuscitation (there is insufficient evidence to recommend a time for clamping in those who require resuscitation) and, (ix) it is appropriate to consider discontinuing resuscitation if there has been no detectable heart rate for 10 minutes, although many factors contribute to the decision to continue beyond 10 minutes. Under certain circumstances, non-initiation of resuscitation could be proposed taking into consideration general recommendations, own results and parents' opinion.

Oxygen delivery using neonatal self-inflating resuscitation bags without a reservoir.

BACKGROUND: Guidelines recommend avoidance of excessive oxygen administration during neonatal resuscitation. Blenders are used in some but not all hospitals. It has been suggested that self-inflating bags without a reservoir deliver around 40% oxygen and could be used to provide an inexpensive and effective technique of avoiding oxygen toxicity. OBJECTIVE: To explore how much oxygen is delivered when using two different brands of neonatal self-inflating resuscitation bags without a reservoir. METHODS: In a benchtop setting, the smallest non-disposable self-inflating bags from the Laerdal and Ambu ranges were tested. Oxygen concentration delivered by these devices under a variety of conditions was measured. 108 combinations of oxygen flow rates (10; 5 to 1 litre/min), ventilation rates (30, 60, 100 inflations/min) and peak inspiratory pressure ranges (20 to 25 cm H(2)O, 35 to 40 cm H(2)O or pop-off valve range, 55 to 60 cm H(2)O) were tested. RESULTS: Delivered oxygen concentration varied depending on three parameters: gas flow rate, ventilatory rate and pressure. At a pressure of 20 to 25 cm H(2)O, mean oxygen concentration delivered by both bags exceeded 70% at any gas flow rate except for 1 litre/min (where delivered oxygen concentration was 60% to 70%). When the pop-off valve was opened at 35 to 40 cm H(2)0, oxygen concentrations fell to 30% to 45% at gas flow rates < or =2 litres/min. The Ambu bag delivered a lower oxygen concentration than the Laerdal bag but this difference was not clinically important. CONCLUSION: When using the Laerdal and Ambu infant resuscitation self-inflating bags without a reservoir, delivered oxygen concentration is >70% for currently recommended flow and pressure settings.

Assessment of the perimortem protocol in neonates for the diagnosis of inborn errors of metabolism.

AIM: To assess the efficacy of the perimortem protocol in neonates with suspected inborn errors of metabolism (IEM). METHODS: Retrospective analysis of medical records from January 2000 through December 2007 was performed. Only neonates (

[Recent advances in research on neonatal resuscitation: an update]. / Investigación en reanimación neonatal: últimos avances.

Coinciding with the Annual Meeting of the Pediatric Academic Societies (PAS) last May 2008 in Honolulu (Hawaii, USA), Professor Colin Morley and his colleagues (University of Melbourne, Australia) held a Workshop on Research in Neonatal Resuscitation. Experts in the field presented their results and future projects over 2 days. The subjects presented during the workshop were: oxygen, air and oximetry; when and where to apply surfactant; neonatal resuscitation research techniques; teaching neonatal resuscitation; cellular physiology and biology; CPAP/PEEP/prolonged inspiration; video recording during resuscitation. Sessions were characterized by an interactive discussion. Our intention is to tell about some of the most innovative aspects that might interest our neonatal colleagues who did not have the opportunity to attend the meeting. As much of the information contained in this article is on experiments based, we recommend the reader not to consider it for immediate application in clinical practice until it has been validated by sufficient proof.

A survey of neonatal resuscitation in Spain: gaps between guidelines and practice.

OBJECTIVES: To audit the knowledge and application of internationally recommended newborn resuscitation (NR) guidelines among delivery room (DR) caregivers of Spanish hospitals. METHODS: A questionnaire-type survey on NR equipment and practices was performed in hospitals of the Spanish National Health System classified according to level of care provided. RESULTS: 88% of the questionnaires were complimented. Limit of viability was set in 23-24 weeks in 78% of the centres. Availability of board-certified and instructors in NR was significantly higher in level III versus level I-II centres (94 vs. 70% and 78 vs. 51%, respectively). No differences in equipment or knowledge of guidelines of resuscitation were found between centres. Substantial differences were observed in supplementation and monitorization of oxygen, and positive pressure ventilation during resuscitation and transportation. CONCLUSION: Equipment availability and knowledge of guidelines of NR does not differ between hospitals independent of their level of care. However, performance during resuscitation and transportation in level III hospitals is in significantly greater acquaintance with internationally recommended NR guidelines.